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EXCELLENCE EXPERTISE INNOVATION

Initiating and Prioritizing Contact InvestigationsTabitha Gibbs, RN

May 4, 2016

TB Contact Investigation 101

May 4, 2016

Little Rock, AR

• No conflict of interests

• No relevant financial relationships with any

commercial companies pertaining to this

educational activity

Tabitha Gibbs, RN has the following

disclosures to make:

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SPECIAL CONSIDERATIONS

Presentation adapted from:

Jessica Quintero, M.E.d

Director of Education

Heartland National TB Center

• Competing demands

restrict the resources that

can be allocated to

contact investigations.

• Identify those most likely

to transmit infection.

Why Do We Need to Prioritize Patients With TB

Disease ?

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• The index patient has

confirmed or suspected

pulmonary, laryngeal or

pleural TB.

• An investigation is

recommended if the

sputum smear is positive.

A Contact Investigation Should be Considered

if…

What Characteristics Should We Consider in Our Decision

to Initiate an Investigation?

+AFB sputum, Pulmonary Cavities, Anatomical site of disease

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• Site of disease

• Sputum Smear results

• Nucleic acid assay results

(other rapid)

• Chest X-Ray results

• Index patient factors

• Resources

Prioritization Factors

Sputum smear positive

• Pulmonary

• Laryngeal

• Pleural

• Extrapulmonary

Site of Disease

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• Smear Positive

• Smear Negative

• Non sputum smears

Sputum Smear Results

Sputum smear negative

Not Generally Indicated If…

Sputum smear has AFB on microscopy and nucleic

acid amplification (NAA) tests for M.tuberculosis

are negative.

Amplified M. tb Direct Test® (MTD): Gen-Probe, Inc.

Amplicor® M. tuberculosis

(MTB): Roche Diagnostics

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• Normal

• Abnormal

Chest X-Ray Results

• Age

• HIV Status

• Other Medical Conditions

• Symptoms

Index Patient Factors

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• Patients with TB disease

management

• Contact investigators

• Fiscal constraints

• Seasonal implications

• Other investigations

Resources

• Gather data

• Evaluate

• Organize plan

• Act on plan

• Monitor and evaluate

So Who Goes First?

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They all They all They all They all qualify qualify qualify qualify as high as high as high as high

risk, top risk, top risk, top risk, top priority!priority!priority!priority!

• Often times the greatest

challenges of a TB contact

investigation are the result

of failure to ask for help

when it is needed.

• Even the Lone Ranger had

Tonto by his side…

Ask for Help

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– Disease

Intervention Staff

– STD Staff

– Preparedness Staff

– Immunization Staff

– Administration

Look elsewhere in the local

health department…

• State Tuberculosis people are nice people, they enjoy helping others, they want to be your friend, part of their mission is to be there for you, asking them for help will make them happy people.

• You have not failed by asking for assistance.

Other Resources

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• Centers for Disease

Control and Prevention

(CDC)

• Available with many

resources at the request

of the state.

• Technical assistance

• Epi-Aid

• Financial assistance

Ask for Help

• How infectious is the patient

with TB disease?

• How long was the patient with

TB disease likely infecting?

• What are the characteristics of

the likely contacts?

• What additional information is

needed?

• How complex is the

investigation likely to be?

Questions to ask

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• What resources will likely be

required?

• What resources do I have

available?

• What resources could be

reallocated?

• Who else could assist?

• Who do we need to inform?

• What are the likely obstacles?

• How do I encourage the team?

Questions to ask

• Once the priorities have

been set, move on, take

action.

• Plans can change.

• Be flexible but not wishy

washy.

• Be thorough and

complete.

Take Action

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Initiation of Other Investigations

Depends On

• Availability of resources to

be allocated.

• Achievement of

objectives for higher

priority contact

investigations.

In many cases, prioritizing multiple

contact Investigations at one time is

not required. In most cases of

medium and low incident states,

multiple patients with TB disease are

not being diagnosed in the same area

at the same time, however, having a

plan and policies in place for how to

address this challenge is critical and

the one time that it is needed you will

be happy you prepared for it.

Summary

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Questions

You are clinical TB case manager at a busy clinic in Brown County, Wisconsin

(home of Lambeau Field and the Green Bay Packers). Three new TB cases have

been assigned to you. You need to review their charts and assign them to

contact investigators.

A. Mr. Garcia is a 35 yr. old agricultural worker diagnosed by a local private physician with extrapulmonary TB of the kidneys. He lives with his wife and 3 children (5yrs, 3 yrs., and 9 months old) in a small, rented house in a rural part of the country. He rides to work every day in a van with 7 other agricultural workers.

B. Mr. James is a 72 yr. old widower who lives alone on the south side of town. He drives himself to the local retirement center 2 miles from his house for bingo and poker four times a week. He was recently evaluated by the retirement center physician because he complained of a productive cough, shortness of breath, fatigue and weight loss. He is AFB sputum smear positive and his culture is pending. His chest x-ray shows a cavity in the right upper lobe. He started a four drug regimen.

C. Mrs. Osaka is a 25 yr. old woman who recently arrived from Japan. She was seen in the Brown County Clinic complaining of shortness of breath, a weak nonproductive cough, fatigue and weight loss. Her AFB sputum smear was negative and her culture is pending. She lives with her husband and parents in a large apartment off Lombardi Avenue. She is currently

unemployed. She started 4 drug therapy.

• Questions:

• 1. For which case(s) should a contact investigation be conducted?

• 2. How should the case(s) be prioritized in terms of conducting a contact

investigation?

Prioritization of Contacts Exercise